Full transcript

DC: Welcome to the BMJ debate. This week I speak to representatives of the BMA and Remedy UK about doctors’ training. Ram Moorthy, chairman of the BMA’s Junior Doctors Committee, and Matt Jameson Evans of Remedy UK, thanks for joining us. The past year has been one of turmoil for junior doctors. There have been resignations, votes of no confidence, government’s apologies, failed computer systems, breaches of security and so on. Ram, in a nutshell, where did it all go wrong?

Ram Moorthy: I think you’ve highlighted all the problems. But the main issue was you had very poor implementation with absolutely no communication with the profession about how to make such a fundamental change to the way we train our junior doctors in this country. And without getting the profession involved in it, the whole process was bound to fail, and that’s where it fundamentally went wrong.

DC: Weren’t you involved in various stages - or the BMA involved - in various stages and consultation? At what point did you realise that the profession hadn’t been consulted enough?

RM: The BMA were involved initially when the principles of MMC - so that was broad based training, structure to our training - was first involved. However, as the policies to implement it came into place, it became very apparent that very little thought was going into what a seismic shift this was going to be. However, as soon as the BMA Junior Doctors Committee started to highlight these problems, we were slowly pushed aside by the various committees involved. That made it very difficult for us to get our voice being heard.

DC: Do you think there would have been less criticism of MMC had MTAS not been such a complete disaster?

RM: I think MTAS was just the straw that broke the camel’s back. The whole implementation process was flawed, and therefore it was always going to be a problem. What MTAS did was it brought everything out to a fore in a short space of time, which really highlighted the flaws with the whole process and how the profession was sidelined by the whole thing. Very few people in certain bits of power were consulted. But essentially the profession as a whole were not. The grassroots doctors were not. Junior doctors were not. And hence we have a process that failed to happen, and caused so much misery to a number of junior doctors.

DC: John Tooke in his report seems to suggest that there were too many voices that were listened to, and the medical profession should be represented by one single voice. Matt, is this feasible?

Matt Jameson Evans: Oh, yes. Absolutely. Where I came out on this was part of the isolated mass of 99% of doctors who don’t really usually take part in medical politics. So that’s where Remedy came from. I think one positive thing can come out of this: it’s a reengagement and a realisation that we can’t just stick our heads in the sand anymore. As grassroots doctors we have to get engaged because the overriding agenda is deprofessionalisation of everything. And MMC is just a single part of that. I think in the future we need to rationalise the medical profession. We have an abundance of different committees, which means nothing to most people, only that they feel so isolated from any decision-making. And I think to make some progress in the big battles that lie ahead - I could list them but it would probably go on too long - things like Tooke’s recommendations to restructuring and simplification of decision-making for the profession have to go forward.

DC: If Remedy had the same clout - the negotiating power - that the BMA has, what would Remedy have done differently?

MJE: What, from the beginning?

DC: From the beginning.

MJE: I think where we came with absolutely direct action that, as a profession, we are an incredibly strong body. I don’t want to abuse that, but I think the medical profession is the strongest profession in the country. There are times when there is an epochal decision, and the epochal decision here is that we think that training is going to be substandard with MMC and we have to make a stand on it. I think that’s what we would have done. We would have said absolutely no.

DC: But correct me if I’m wrong. Didn’t initially doctors want run-through training?

RM: I think doctors wanted, not run-through training, but doctors wanted some clarity to their training. What we all realised was the SHO grade was a bit of a mix, a free for all. Some people went through the SHO grades very streamlined. Some people seemed to take a lot of time in it. And a lot of people were doing jobs with no training at all. They were not making any improvement in their career prospect. They were not making any improvement in their specialty training, which is where the problem came about why we needed to somehow rationalise the SHO grade. And Sir John Tooke has essentially done a similar thing in his report with a Core training scheme that is time limited to three years. But just to bring back to Matt and the whole direct action thing - I think, Matt, that the JDC did do that. We did highlight our voices. But as you’ve already said, there are so many different committees that speak out on this, that there was always some group that was willing to support what the government’s agenda was. And that’s what they then pushed forward with, because they had some form of support within the profession.

DC: So are you saying that the BMA is trying to represent too many different interest groups here?

RM: Well, what we’ve got to look at is - I mean, the BMA is the sole voice of negotiating within the terms and conditions of service. So we negotiate directly with government regarding that. When it comes to education and training matters, there are a number of different stakeholders that are involved: the Royal Colleges, the deaneries, the various specialty associations and their specialty trainees groups. So there are a number of people who’ve got an interest in where training goes. Medicine is no longer “one model fits all”. The training that I required as an ENT surgeon is very different from what Matt may require as an orthopaedic surgeon, will be different to what the GPs want, which is different to what the physicians want. But all of those need to be listened to, and that opinion needs to be taken forward. But what the government did was that they failed to listen to the commonsense opinion that was coming out from grassroots doctors that trying to make such a massive change - changing the way we recruit doctors, changing the way we train doctors, and changing the way we select doctors - was going to be a problem.

MJE: I think the answer to your question is no. If you are talking about doctors who are going to be affected by these decisions, no doctor I know was in any way consulted about run-through training per se. I think it’s time to release the grip of educationalists over the whole profession who run rough shod over any rational decision-making about training. A lot of the decisions that are made about MMC are from speaking to other educationalists. They’re made on very poor evidence. There’s plenty of contradicting evidence, which isn’t news, and I think to just take that approach to a whole reform on very scant pilot studies is a folly. I think if they had consulted the people who were going to be affected by these decisions, they might have had a different reform in the end.

DC: So have doctors’ groups or doctors’ representatives failed in their jobs to represent the interests of doctors then in the whole process?

RM: What happened was the rationalisation of the SHO grade was really all that was meant to happen. MMC somehow exploded out of all of this - the term “run-through training” and various other things which had not ever been proposed or contemplated. And nobody is willing to admit who came up with this idea that we needed to have one model fits all run-through training.

MJE: But the railroad through - the rationalisation of SHO grade essentially, for example, just to make a basic surgical training or basic medical training available to all is a great idea. But the segue into a whole rail through from beginning to end - that’s a catastrophe because it has no flexibility.

RM: That really was brought in without any kind of evidence behind it. If you actually have a look at the documents that came through, none of it was in there.

DC: So how do you balance stability with flexibility? It is quite difficult.

MJE: You need buffers, I think. And one of the buffers would be a gap between SHO and registrar training as we’ve always had. It allows flexibility. It means people can move sideways into different careers - as humans need to have these opportunities. We know that there are going to be immense problems if we carry on with a very rigid single pathway essentially from SHO right up to the top.

DC: So you’re broadly in favour of Tooke’s recommendations then?

MJE: Absolutely. I think to disregard Tooke and his recommendations is a disaster. We have to embrace Tooke and then sort out any small differences after that. If the profession doesn’t get behind Tooke and make it impossible for the government to wriggle out of Tooke - which they will try to do - we’ll be ruined, essentially. Tooke is the best thing that’s happened in the last few years.

DC: And how are you going to lobby for the full implementation of Tooke? Both of you - as a representative of Remedy and a representative of the BMA - what are you doing so junior doctors know what you are doing on their behalf?

RM: Essentially, at the moment, we represent the junior doctors on the Joint Medical Consultants Committee who have released a press statement last week supporting Tooke, and especially supporting the idea of the NHS Medical Education England as way of taking forward training, which I think the profession is very broadly in favour of and wants to take place. I’ve released press statements, again, saying we broadly support Tooke and especially the ring fencing of training budgets to ensure that we can continue to train doctors for excellence, which is what the underlying ethos of Tooke is. Unfortunately the Darzi next stage review is going to overlap with a lot of what Sir John Tooke has said, so we are representing there that Sir John Tooke’s recommendations have to be taken forward. It’s what the medical profession want. It’s what the medical profession see as being the way that we can maintain the standard of excellence that we have, and that we need this for the long term as well.

DC: There’s a couple of things that have come up in the Tooke report that need further clarity. Some of our readers have asked, what are your positions on the NHS Medical Education England - or NHSMEE as it’s been known? Who should run this body?

MJE: I think Tooke himself is a great example of someone who is not part of the usual suspects of UK medical education and training reform. He’s been consistently excellent. We were incredibly suspicious about him when we first heard about him. We thought he might be some kind of government patsy sent in to fulfil their objectives. He’s consistently surprised us with his recommendations. So I think when we’re talking about NHSMEE, we need to find someone like him. Whether or not he would be interested in it as a transitional post, I’ve absolutely no idea. But he’s inspiring in that these people do actually exist. In a workforce that is completely disillusioned by its leadership, he’s proved an exception to the rule. So we have to find someone as good as him. Remedy would back a universal election for a person to run training in this country, and that could be done online.

DC: Done online.

MJE: Yes. It’s very straightforward to set up. Technology isn’t being used by the profession and it should be.

DC: And what’s the BMA’s take on this, Ram?

RM: NHSMEE, as Sir John Tooke in his report has said, is vital. We need to have the budget ring fenced. That budget then needs to be used to train doctors to excellence. And that’s the only way that we can do it. We’ve seen so many times recently with training budgets being used by trusts to cover their financial deficits. How NHSMEE takes place I think will need a lot more debate. There are a number of issues involved, as in who needs to be involved, how do we select? And I don’t think these can be just discussed in such a small forum. We need to have the profession decide what they want to see.

DC: Another concern that has come up is the sub-consultant grade. Is it really feasible that everyone in training will make it through to consultancy, Matt?

MJE: Well, that relies on the amount of consultant numbers. Something Remedy got behind right from the beginning in our first manifesto in 2006 was let’s sort out workforce planning and let’s get behind expansion of consultant posts as to what was planned when we expanded junior doctor posts. So consultant-delivered services was the name of the game. They’ve reneged on that. So we now have a problem. The question is, what is going to happen to - what is a reality now - that there is a mushroom of time-expired SPRs coming through? The two options are we expand consultant numbers, or alternatively we have this problem of time-expired SPRs. They can either go to a different grade, which then keeps an option open for consultancy in the future - so like the old SR grade - or we create a permanent sub-consultant grade, whatever you want to call it. I think ignoring this as a problem is at our peril. We’ve seen what happened when a problem happened to the SHOs. We’ve got 12,000 SHOs who are now effectively looking at career termination. Is that going to happen to the mushroom of people coming through? Well, if we don’t have a future for them, ie we just stick to a very blinkered view that consultancy is the only option, then I think writing off those people is as serious, if not more serious, than the SHO problem. A solution needs to be found. I think it might be unrealistic to think that the consultant posts can be found. We’re lobbying directly to government front bench politicians about this right as we speak, and we want to put the maximum amount of pressure on government to create those posts.

DC: And, Ram, what’s the BMA’s take on this?

RM: Fundamentally we’re opposed to the sub-consultant grade. We do not see the need to develop a new grade to fit into what we already have. The consultant contract is enormously flexible. And Matt has quite rightly stated that this is atrocious workforce planning, that people went into registrar training because there was meant to be consultant expansion for them to go into. That’s how it had always been planned. So there is a need for these doctors within the service. What the service at the moment feel, is they feel constrained financially. However, what they don’t realise is how flexible the consultant contract is to allow us to try and employ more people. So what we’re doing - the BMA as a whole, so not only the Junior Doctors Committee but the Consultants Committee as well - is pushing to show where the trusts need to employ people to provide service to their patients, especially with so many government targets coming ahead that need a consultant-delivered service for it to happen. So consultant expansion needs to happen, but also we need to understand that the consultant contract is enormously flexible to allow people to be employed in the grade without what the service thinks is some maximum point in it.

DC: And do you really think the government will expand the number of consultant posts?

RM: Well, there’s a need for it in the service. They have shown that they need more people to provide the service. This is where all the figures came from. The service needs it. The public need it. The government needs to look at how they are going to fund it. Trying to put an extra grade in will not benefit anybody. It will not benefit those who are currently in training. It will not benefit those time-expired registrars.

DC: Why do you think Tooke put it in his report, then?

RM: Tooke put it in his initial report and then changed it. If you look at his new report he talks about a single box, with specialist CCT holder moving seamlessly between the two. And I think he fully understands that it is because there’s a lack of understanding within the NHS as a whole about how the consultant contract is flexible to allow for service expansion to take place. We do not need a separate grade of post-CCT holders below that of a consultant.

MJE: Whether or not we need it, essentially these decisions are out of our hands because of “foundation hospitalisation” of the whole country. Foundation trusts don’t have to appoint - they’re going to be dictated by market forces. Therefore, whatever we say and what density of consultants that we presuppose for a given population, the foundation trusts are going to be guided purely by market forces. Appointing short-term contract locum consultants - as they seem to be doing at the moment - will be in their own interests. So I think we need more rigid central planning of the consultant numbers.

RM: Well, locum consultants are on the consultant contract, and they are on the consultant pay scale as well. In all essences they are treated as consultants, apart from the fact that they don’t have a permanency of contract. And yet, after 12 months they are essentially treated as permanent employees as well. What you’re calling for - if I get it right, and I hope you’ll correct me - is if you ask for a grade to sit between the specialist registrar grade, the post with the CCT, and the consultant grade - which is what you’re saying - then you are asking to formalise a grade in the middle there with the terms and conditions of service and their own salary scale, which I think is fundamentally wrong, because we do not need a grade there. As Sir John Tooke says in his report, a CCT holder has shown that he has got the knowledge, skills, and attitudes ready to be appointed a consultant in the NHS. We’re aspiring to train to excellence, which is what the underlying ethos of that report is. So if we are then saying to people, yes, train to be excellent. But, sorry, the trust isn’t going to afford you, so we’ll appoint you into another sub-consultant grade. I’m sorry but I can’t - trainees do not train for that. You’ve got to have what the end goal is. The consultant contract has got 84 pay points on it. There are ways to use it to do this without introducing a separate grade that’s going to be cheaper and easier to employ and will be, you know, a juggernaut for trusts - if what you’re saying is true - for juggernauts to employ people who are CCT holders.

MJE: I don’t understand what - I certainly don’t think that we’re suggesting you have a separate grade that has no career prospects to consultancy. But what I am suggesting is that in the future there will be a problem of time-expired SPRs - without a doubt. What I’d like to know is what you think is going to happen to that cohort of people.

RM: But why can’t we use the current consultant contract, so they are employed on the consultant terms and conditions of service on the consultant pay scale, and we can work out ways of making that more flexible so that we can employ people in an independent practitioner post, which is what the CCT holder involves. And then you can use that to then create what the service requires and what people need to do. What we don’t need to do is have a separate grade, because as soon as you put a separate grade you’ve got barriers for people progressing across. It will always end up as some sort of a dead end post. And because you have to put them into a gap between the consultants and the juniors, you’re again limiting their financial ability as well - not only their clinical motivation and ability but their financial ability. So why not use what the current consultant contract allows you? I mean, 84 points I think is -

MJE: But do you think those posts will exist? In orthopaedics, for instance, there is going to be about three in 10 in the country who are going to be getting consultant posts under current predictions. So what exactly does the BMA think should happen to those seven out of 10 - the majority of people? This is not my statistic. This is the BOA.

RM: We already know what your CCT is training you up to be. What a sub-consultant grade will be - please correct me if I’m being wrong - but what you’re actually proposing -

MJE: We’re not proposing for a sub-consultant grade. Let’s be clear about that right now.

RM: So you are asking me how are we going to employ these people? Or are you saying to create something for them to go into? I’m not really sure what you’re saying.

MJE: I’m saying that what appears to be happening is that there will be a similar situation. Being part of a group of 12,000 doctors who are looking forward to no future, I’m very concerned about the cohort of people who are currently in SPR positions who have no apparent future planned for them. And I just wonder what they can aspire to and what the BMA is looking forward to. Consultancy is probably not going to be an option for them in the current climate. We’ve made mistakes in the past of saying -

RM: But why not? Why do you see consultancy not being an option for them?

MJE: By the simple numbers - the fact that there is a certain amount of consultant posts and a certain amount of doctors. And the predictions are - by groups such as the BMA - is that there won’t be jobs for them.

RM: Well, no. The current numbers are based on the need that we need to expand our posts. That is well recognised by everybody that there is a need for consultant expansion. And that is what these numbers coming through were meant to take up. That’s why they were being trained, ok?

MJE: Ok. But given the fact -

RM: So therefore - let me finish - therefore, what we are saying is that the service needs them. We’ve not pulled these posts out of thin air. There is work available there. There are patients that need to be treated, patients that need to be seen for these people to do. And therefore what the government needs to do and what the service needs to do is do what the intention was when these people were first appointed: to use them to treat patients. Not to try and cheapen the service that’s out there. Not to try and use cheaper forms of labour to try and deliver second rate healthcare. These people are trained to provide the consultant delivered healthcare that this government promised in 1997. And that’s what they need to be employed to do. Trying to find other ways of employing them in a grade below a consultant is not needed. There are ways that this can be done and that’s what we are lobbying government for. I do not see a need currently to be sitting there trying to look at a sub-consultant grade to try and put people in, which will be a dead end job.

DC: Can I just move the debate slightly because we are getting kind of hung up on that, which is clearly an interesting issue and something that possibly we should revisit. But there’s been other concerns that have been flagged up through questions. One of these that’s come up repeatedly is the European Working Time Directive. Some juniors are worried that with less overtime the salaries are going to go down. Others are concerned that they’ll be less well trained at the end. And some suggest that it has lead to thinner cover and prolonged span of nightshifts. Ram, the BMA lobbied for the implementation of the European Working Time Directive for doctors, didn’t it, initially? Does it still support it?

RM: The European Working Time Directive is really health and safety law. When this was originally being proposed and being lobbied - I was a junior doctor at the time - but we were working 80-100 hour weeks and therefore there was a definite need for some form of legislation to help protect and prevent doctors working excessively. What is more than apparent is that there is no way the trusts can cope with ensuring the service is met and training, more importantly, is delivered within the time limit. But what I’ve got to make clear is that that time limit is outside our control. That time limit is set by European parliament. The only thing that the BMA lobbied for was to prevent the government extending when that European law would affect doctors, and we got it to 2009. But there was no way that we were going to be able to lobby to be outside the European Working Time Directive.

DC: Other countries have managed to skirt round the issue, haven’t they?

RM: Other countries are doing it - have done it - without legislation. And the government is now open to legal cases should they not impose the law. And I think that’s what we need to make clear.

DC: And what is your position on it now? Are you going to be - because in the Tooke report he basically sees European Working Time Directive as being quite disastrous, to be perfectly frank.

RM: We’ve been lobbying over the last couple of years to try and make the law as flexible as possible to ensure that training is delivered for those people in specialties that require the training to be delivered with slightly longer working hours. But what we’ve got to remember is that certain specialties do feel that they are getting their training in 48 hours, and do not see the benefit or the need to work above and beyond that. What needs to happen is - we agree with Sir John Tooke that it needs to be important that we highlight the specialties that can’t be trained within the time limit, and that we look at ways of maximising the training opportunities that are available to get them training. But changes to European law cannot be done just by the BMA. They need to go up to Europe and need to be discussed in parliament and changes need to be made there. So unfortunately those are going to be happening in the next few years. And we have been lobbying parliament to try and do various aspects of this.

DC: And what’s Remedy’s take on this?

MJE: Very clear. We completely reject it as a very negative thing for training. There will be specialties that certainly don’t necessarily feel that they need to have more than 48 hours but it’s much more serious that there are specialties that feel they need over 48 hours and can’t have it.

DC: And doesn’t this highlight one of the problems of being the voice for junior doctors? That in actual fact, junior doctors are a heterogeneous group of people, and representing the views of junior doctors is massive.

MJE: Sure, but in this case there’s an upper limit. The upper limit doesn’t mean that you have to work, say, 56 hours a week. It just means that you’re not restricted. I think there are ways around the Working Time Directive that need exploring. We’ve certainly got a plan. I’m not going to go in to it now. But it needs to be discussed. It’s absolutely crazy. The training is being eroded at all levels and this is just another part of it. Whether it is surgical assistants taking opportunities away from junior doctors -

DC: In what other ways are training being eroded, in your view?

MJE: As I said, the increasing prevalence in non-medical practitioners involved in medicine, taking away training. In that way -

DC: Don’t you think it lets doctors get on with top tasks that only doctors can do?

MJE: No, I don’t. I think, again, the market forces are dominating foundation hospitals’ decisions, so that it may be more cost effective to have a nurse practitioner doing basic operations, which a lot of people are pushing for. But it’s certainly not cost effective in the long term for training - the kind of costs that the foundation hospitals don’t see in the short term, but which have a massive implication in the future. So that’s another reason.

RM: Just two things. About the non-medically qualified practitioners, I personally have been going on about it for a number of years. The JDC have got a very clear policy on the problems that non-medically qualified practitioners have. I’ve got published research that shows that it’s not something that patients want either. And actually they’re not cost effective. If you look at all the studies that have been done, I think only one study has vaguely shown that they’re cost effective. Otherwise they’re very expensive to train, and actually the cheapest person per patient on the workforce is the consultant. That’s what really needs to be highlighted, that it’s a properly trained medical workforce that delivers very high quality - but more importantly to the bean counters - cost effective healthcare, which the consultant will see the patient the best. And the medical team will see the patient the best. And it’s not actually cost effective to employ a non-medically qualified practitioner.

DC: So do you think all these measures - the European Working Time Directive, cutting down training, giving tasks to non-doctors - do you think it’s a way of streamlining the medical profession?

MJE: I think we’ve been accused of being a single-issue group, and I suppose if it was to be a single issue group it would be about deprofessionalisation. And that is our single issue at the moment. We probably will expand. But I think it affects every doctor in the country from consultant down to medical student. So I think, yes, everything that you talk about is true and it’s not going away. Remedy, and I’m sure the BMA would want to take this on in the future. There’s going to be limitless battles about this issue in the future.

DC: So you talk about Remedy in the future. What are Remedy’s plans for the future?

MJE: We aim to consolidate our position, make ourselves probably more representative than we’ve been.

DC: I’d like to go back to this idea of representation, and it’s to get more of an idea of how you go about representing the views of your members. Ram, what does the BMA do to really represent the views of its members?

RM: We’ve got a very clear structure. We’ve got the regional Junior Doctors Committees, which are based around the country. And every junior doctor - you do not have to be a member of the BMA - is eligible to attend those meetings and speak and let their voice be heard. Each of those meetings elects a committee who send a number of representatives up to the UK Junior Doctors Committee, who then elect the office holders and I’m the elected chairman of that group. In the devolved nations, Scotland, Wales and Northern Ireland all have their own Junior Doctors Committees, which are again formed on a regional basis and then they have a national committee which comes and sits on UK JDC. The structure is there. And the important thing is getting people involved in it. And that’s why over the next few weeks I’m actually attending a lot of the Junior Doctors Committee meetings to give people the opportunity to come and speak directly to me and hear what’s going on, and hear what’s being said.

DC: And Matt, why didn’t you agitate from within, then, if there’s this forum for junior doctors to make their feelings known? It seems that you’ve splintered the junior doctors and there’s two different groups. Why didn’t you agitate from within the BMA so junior doctors appear to be one unified force?

MJE: Well, Remedy came out of a feeling of isolation. I mean, sure, I could have gone to my local BMA meeting, but I felt that around me there was as sense of complete frustration and that needed to be captured. And I don’t think that necessarily the representation of the BMA translates into a thrust of action. We needed action quickly and I didn’t think that rising through the ranks of the BMA was up my street, to be honest.

DC: And do you think holding vigils outside parliament generates support and really shows how junior doctors are feeling?

MJE: I think it’s paradoxical that Remedy, which stands as a fairly - other than our polls and balloting people for their opinion - we’re very unrepresentative. And yet, I think we have represented the opinion of most doctors in the last 12 years better than the BMA to be honest. If you ask your doctor on the street, I think they feel we captured that kind of moment better than the BMA.

DC: But does it mean you’re taken seriously by government?

MJE: To be honest, I think our greatest success has been at a high politics level, and a lot of our campaigns have been directed at MPs. I think we carry a certain - maybe more weight than we should within parliamentary politics.

DC: This idea of your being taken seriously by MPs - there’s a slight feeling that possibly you’re a little too close to the Conservatives. David Cameron spoke at your rally. The Daily Telegraph have taken up your campaign. Are you allied with the Conservatives?

MJE: When we started - to address the Telegraph issue - we’d take whatever publicity we could. Our first press release went to the Guardian and it got picked up by the Telegraph. Similarly, for the march, our first touch with the politics was through a Labour MP called Ian Gibson, and we’ve consistently maintained a good relationship with him. The fact that the Tories really got on board with us - again it would have been naïve and stupid to have rejected that in any way - shows, in my view, that they’re politically very astute and picked up on what became a very big issue last year. Whatever party it was, none of us were interested in party politics. It just happened that the Tories in some ways responded to us the most.

DC: So do you consider yourselves to be neutral politically?

MJE: Absolutely neutral, yes. We’ll take whoever speaks some common sense about what’s happened.

DC: And I’d like to turn you to the future of the JDC. What’s the JDC’s ultimate goal?

RM: I think that both organisations are quite complimentary in that the fundamental aims are exactly the same. What the BMA and the JDC can provide is that we are there discussing policy at the high level. We’re not in parliament where, unfortunately, certain things can be said, but it’s very difficult sometimes for things to be acted on. You can highlight issues and problems, and part of the reason that works is because, obviously, the opposition want to pick up on where the government has either failed in policy implementation or they’ve been untrue in what they’ve said. But what we have the ability to do is working with, obviously, how the health service is being taken forward. And it’s vital that the junior doctor’s view is put forward there. We’ve got so many fundamental changes going on, and especially currently with Lord Darzi’s review of the health service, and this involves everything from workforce planning to training to education regulation. And these are fundamental meetings which are going to determine how we get taken - and how junior doctors get taken - in the future. And as Matt has correctly pointed out, there is a very common theme to try and amalgamate all the healthcare professions into one amorphous block. But I think it’s very important that the professions are kept very distinct. And that’s why it’s vital that the medical profession, especially in our case, the way we get taken into the future is the correct way for us. So that means that we have high quality undergraduate education, high quality postgraduate education, enabled to deliver high quality care at the end of it. And we have a career that people aspire to and that will continue to attract the best applicants, as we’ve always expected, into medical school.

DC: I’m sure your aims are fairly similar to those highlighted by Ram.

MJE: Absolutely. I think we operate in very different ways. We have differences of opinion but obviously our goals are the same, which is to maintain the high standards that we’ve enjoyed for the last 100 years in this country. I feel very bleak about the future, to be honest, but I think there’s a really good fight to be had. And it’s a good fight. It’s trying to maintain the highest standards of patient care that we can. And so we certainly don’t see any conflict with the BMA. If it’s anything it’s competition, and that has to be healthy because we all have the same goal.

DC: And what’s the prospect of BMA and Remedy working together?

MJE: Well we already do work together. So, as I said, we work together where it suits us for both of our ends. Where we come into conflict - I’m sure we’ll be in conflict in the future but I see that as a positive thing and I hope Ram would too.

RM: As Matt said, we work together in a lot of ways, and none of the conflicts that we’ve had have actually been over policy as such. They’ve not been over how we see ensuring that junior doctors have a fair system for this year’s selection, trying to get adequate number of training jobs and what we see the fundamental aims of training to be. That’s not been where our conflict arises.

DC: So you think there’s a need for two different approaches?

RM: I think if junior doctors feel that they need the availability of two different ways of getting their voices heard, then that’s their right to do so. I’m not saying that the way the BMA does it is correct. And neither am I saying the way Remedy does it is correct. They’re both very complementary ways of ensuring the voices are heard. As we said, with our structure, any policy that’s enacted by the JDC has got to be voted on by the committee as a whole. And hence a number of views are brought up and heard. And they’ve all got to be ensured that they are presented correctly whenever we do anything - when our policy goes through, when we make any responses to - even the Tooke inquiry. It was vital that all the various responses within the BMA had their voices heard. And that’s what I see as the benefits of the structure that we have.

DC: Doesn’t that make you a little slow to react?

RM: We can be slow to react, because we’ve got to ensure all voices will be heard. And in some ways that’s how Remedy have benefited so much. They’re very quick to react in the way that their structure is at the moment. Whether that changes as things develop is difficult to say. But what it means is that when we do react we have a very considered opinion. It’s not a knee jerk response. But importantly, we’ve got a very clear policy on a number of issues that still allows us to act quickly on those, and present a very considered, debated opinion both to the public and to government as well. It is one of the big benefits of the BMA as it is.

MJE: Maybe another difference is that Remedy’s got less to lose. We’re not a massive organisation. We can take on fights that, if it blew us out of the water, it would be a loss. But it’s not a massive institution. So we’re quite prepared to take on high-risk strategies which maybe the BMA aren’t. And they fulfil different roles too.

DC: Ok. Thank you for joining us Ram Moorthy from the BMA and Matt Jameson Evans of Remedy UK. That was the BMJ debate. Please give us your feedback on BMJ.com.

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DC: The BMJ: helping doctors make better decisions.